The Uninsured and Seniors: Health Care for other Significant Groups that are Underserved in Rockbridge County

By Mac Trammell

Doralee Carter, 40, didn’t consider health insurance a priority, until she had to have two toes amputated.

About a year ago, Carter walked out of her parents’ two-story white home in Kerrs Creek. Her doublewide, where she and her four children—and 10 or 11 adolescent chickens—live, sits a stone’s throw away.

As she walked off the porch of her parents’ home, she stepped on a rusty nail. It punctured the bottom of her shoe, her skin and finally, the bone in her big toe.

She felt nothing because of her diabetic neuropathy, a nerve disorder which can cause numbness in the legs and feet, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

She attempted to care for the injury on her own.

“Soaking it, cleaning it, putting antibiotic ointment on it,” she said, “you know, doing what I know how to do. … By the time I got to the doctor, it was pretty infected. ”

By then it had been four days. Her rationale behind self-care for such a serious wound was a financial one. She didn’t have health insurance and didn’t want to pay a hefty medical fee.

“I wasn’t insured before,” she said, “because, in the state of Virginia, you either have to be pregnant or disabled, and I was neither one.”

Finally, she went to the Rockbridge Area Health Center, which referred her to a general surgeon. After putting her on antibiotics, the doctor decided her toe needed to be amputated.

After surgery, she went home, thinking the infection had been neutralized. But six weeks later, the infection had spread to the next toe, and it also had to be amputated.

Luckily for Carter, she found out before the first amputation that she qualified for Medicaid. But her decision-making prior to that discovery represented how many rural residents prioritize health care.

“They don’t have that disposable income for that,” said Mary Looney, chief operating officer of the Rockbridge Area Health Center.

“If you’re uninsured, the price of health care is so high that you’re probably not going to go [to the doctor],” said Kelly Brotzman, a visiting assistant professor in Washington and Lee University’s Shepherd Program for the Interdisciplinary Study of Poverty and Human Capability. “Uninsured people are paying more than insured people for most of their doctor visits. That’s an uncomfortable fact.”

She also said she believes there’s a high rate of neglected care, like Carter’s infected toe, due to expensive doctor’s fees coupled with a lack of insurance.

Census data shows that as of 2015, 12.5 percent of Rockbridge County was uninsured, down 5 percentage points from the 2012 Rockbridge Community Health Needs Assessments estimate. That rate is about 2 percentage points higher than the statewide average for 2015. The state’s rate of uninsured citizens, though, dropped only 4 percentage points during the same timeframe.

10.4%

of the Commonwealth of Virginia is uninsured

12.5%

of Rockbridge County is uninsured

The uninsured rate for Rockbridge County residents living below 200 percent of the federal poverty line was 20.3 percent in 2015. For 138 percent or less of the poverty line, it was 21.5 percent. These numbers were nearly identical to statewide percentages.

The Rockbridge Area Health Center became a federally qualified health center three years ago. It has been providing inexpensive health care to residents of Rockbridge County since 1992. Carter, a board member of the health center, says that services have improved immensely over the last three years.

“Before, there wasn’t a whole lot of care given to diabetics,” she said. “Not a lot of knowledge, information. Not a lot of help. But they’ve really stepped up in a lot of ways.”

The health center uses a sliding payment scale, a mandate for federally qualified health centers. The sliding scale provides discounts—ranging from $5 to $55—for residents who live 200 percent of the poverty line or below.

The federal government says that the poverty line for a single person is $12,060 per year. An annual salary of $24,120, or twice as much as the poverty line, would equal 200 percent. Income of anything less than that annually would qualify a single individual to apply for discounted rates under the sliding scale. The poverty line adjusts for family size, as does the sliding scale.

“If someone does not have health insurance, then visit costs themselves would be discounted based on your income,” said Jane Horton, chair of the board of the Rockbridge Area Health Center.

Looney said 68 percent of the Rockbridge Area Health Center’s patients are below 100 percent of the poverty line, meaning that the $22 nominal fee charged per medical visit may be difficult to pay. But if patients can’t pay, they won’t be denied health care.

“We will not turn somebody away for their inability to pay,” said Looney. “So if they don’t have $22 when they come to check in for their appointment, we’ll have them sign an acknowledgement that they do still owe that $22 and we’ll work with them to do a payment plan.”

Carilion Stonewall Jackson Hospital uses a similar policy, but on a larger scale. The hospital has nearly $7 million in uncompensated care budgeted annually.

“We’re going to see everybody,” said Charles Carr, CEO of Stonewall Jackson Hospital. “We want to be able to take care of everyone. Whether you can pay or not, you’re going to get the same treatment when you come in.”

Caring for the elderly

It takes roughly 40 minutes to drive on I-81 from Lexington to Roanoke, and a bit longer to get into the city. For the entirety of that ride on May 18, 2016, Lynda Bassett-de Maria suffered through a heart attack.

“It was a little bit scary,” she recalled “but I usually don’t get frightened in situations until after they’re over. Then I fall apart. In the midst of a serious situation, I’m usually pretty calm and try to figure out what needs to be done next.”

It became apparent at Carilion Stonewall Jackson Hospital that her condition was too serious for the hospital to handle. The doctors loaded her into an ambulance. With her husband, a retired journalism professor at Washington and Lee University, trailing behind, EMTs drove her to Roanoke where she was hospitalized for five days.

According to the American Heart Association, cardiovascular disease was the cause of death for nearly 400,000 females in 2013. Bassett-de Maria was lucky that she made it to Roanoke.

Care for the elderly in Rockbridge County is an issue because 20.7 percent of residents are age 65 or older. Only 12 percent of the entire state of Virginia is that old. Nearly 45 percent of Rockbridge County ranges upwards of 50, while 31.5 percent of the state is 50 and up.

12%

of the Commonwealth of Virginia is 65 or older

20.7%

of Rockbridge County is 65 or older

The elderly are affected by the same transportation issues that plague the uninsured, but for different reasons. Movement in general is difficult for the elderly, and many seniors no longer have cars because their loved ones find it dangerous for them to be on the road. Others live in assisted living or nursing homes.

The Mayflower is an assisted living center located on the corner of Main and Jefferson Streets in Lexington. The 38-bed facility costs between $2,200 and $3,400 monthly.

Becky Tacy, licensed administrator at the Mayflower, says there are nurses on staff, some of whom specialize in dementia care and heart issues. Those nurses provide help with administering medications, says resident Barbara Snowden, 81.

The retirement community also contracts with occupational and physical therapists to come in three or four days a week. If anything more serious occurs, the Mayflower will refer residents to nursing homes, such as Heritage Hall Health and Rehab Center, or to Carilion Stonewall Jackson Hospital.

Luckily for three Mayflower women—Edna Clarke, 96, Kittie Bishop, 94, and Anne Lee McDaniel Glenn, who said she does not know how old she is—they have not needed any special medical treatment.

“I’m as healthy as a horse,” Glenn said.

Clarke agreed that she’s in good health, but said that old age has taken its toll.

“I haven’t had any serious problems,” she said. “I’m just worn out! I’m 96 years old!”

Tacy described Mayflower residents as mostly veterans, like Clarke who was a nurse during World War II. The seniors mostly fall into a middle class background, says Tacy.

Across town, residents of the Kendal at Lexington retirement community are wealthier, says Charlotte Sibold, its health services administrator.

Kendal charges $180 per day for assisted living or about $5,400 a month. The 20-apartment assisted living facility at Kendal provides many of the same services as The Mayflower, such as help with bathing, dressing and medication administration.

Kendal charges a maximum of $276 daily, or $8,280 monthly, for nursing care, which requires more attention for residents who have advanced cognitive impairments. Some of those who live in the 60-bed nursing center, which is about to undergo renovations, need total care, “meaning that we do everything from bathing, dressing to feeding the individual,” Sibold said.

$5,400 to $8,280

Cost of Kendal per month

$2,200 to $3,400

Cost of Mayflower per month

The 17-year-old Kendal at Lexington contracts with a medical director, Dr. Alfonso D. Brochero, who makes regular visits with patients per Medicare regulations. He visits two or three days a week, while a nurse practitioner comes to Kendal three or four days a week.

There are limited emergency services available at Kendal. But, if residents need stitches or fracture bones, Kendal will send them in an ambulance to Stonewall Jackson or another hospital in the area.

Transporting patients to specialists in Augusta or Roanoke can be costly, Sibold said.